The United States is in the midst of an opioid overdose epidemic, as the Centers for Disease Control and Prevention (CDC) reports that every day 78 Americans die from an overdose involving an opioid drug. Though it’s the smallest state in the US, Rhode Island is not immune to this public health concern, as the Office of the Governor reports that more than 1,000 residents have lost their lives due to an overdose in the past five years. According to a press release published by the State of Rhode Island, overdose fatalities have risen 250 percent within the state since 2011.
Opioid drugs are likely the driving force between these staggering overdose deaths, as more than half of all overdoses in 2015 involved fentanyl (a powerful and potent opioid narcotic).
Governor Gina M. Raimondo proposed an Action Plan to tackle this public health crisis in Rhode Island in May 2016, asking the General Assembly for $4 million in funding in the FY 2017 budget. The governor’s Overdose Prevention and Intervention Task Force is a goal-oriented strategy to prevent overdoses, increase treatment accessibility, and promote recovery from addiction involving opioid and other drugs.
In 2015, approximately 257 people in Rhode Island died from a drug overdose and in just the first four months of 2016, there were 46 fatalities, according to the Rhode Island Department of Health and data published in the Rhode Island Overdose Prevention and Intervention Task Force Action Plan. Almost 80 people each month also seek emergency department (ED) treatment for overdose in Rhode Island. The overarching goal of the governor’s Action Plan is to reduce opioid overdose deaths by one-third in the next three years and to significantly reduce the number of monthly ED visits.
Governor Raimondo plans to do so using the following four strategies:
For every drug overdose, there are around 100 individuals struggling with an addiction involving an opioid drug. The American Society of Addiction Medicine (ASAM) classifies addiction as a recoverable brain disease, and Governor Raimondo hopes to reduce the negative stigma surrounding this disease with a public education and community outreach plan as a complement to the Overdose Prevention and Intervention Task Force.
The first step in reducing the number of drug overdoses is to focus on preventing them in the first place. Prescription opioid drugs are often diverted to be used and abused for nonmedical, or recreational, purposes. These drugs enhance feelings of pleasure while decreasing stress, tension, and pain sensations. They can produce a euphoric “high” when taken in higher doses and outside of a necessary and legitimate prescription. Individuals may invent or exaggerate symptoms to try and get these powerful pain medications, or they may go to multiple doctors (called “doctor shopping”) to try and get more prescriptions.
One of the tools available at the state level to prevent this is an electronic database that monitors the prescribing and dispensing information of these commonly diverted and abused prescription drugs. The CDC reports that these Prescription Drug Monitoring Programs (PDMPs) are among some of the most promising state-level interventions to cut down on abuse and diversion of these potentially dangerous drugs. A PDMP can identify patients who may be at a high risk for abuse and addiction, giving prescribers information on the individual’s personal history of controlled drug use. Additionally, the Rhode Island Department of Health (RIDOH) is participating in the multistate Heroin Response Strategy and using the Fusion Center to minimize supply and demand for the illegal opioid drug that individuals may turn to when prescription opioids become harder and more expensive to obtain.
Rhode Island’s Action Plan intends to get 100 percent of all prescribers enrolled in the state’s PDMP, as more than 15 percent are not currently enrolled in the program and only 40 percent of those who are actually use it. Prescribers who fail to enroll in the program will be reported to their respective professional boards.
Rhode Island also plans to look at alternatives to opioid therapy, limit the duration of opioid dosing, restrict opioids to only those with high needs, and support hospitals in their policies to only prescribe opioid drugs from an emergency room for three days or less.
Additionally, many people are prescribed both opioid drugs and benzodiazepine drugs at the same time – over 5,000 people in Rhode Island each month in 2015 – which can also increase the risk for overdose, the odds for problematic drug use, and the likelihood of developing an addiction involving one or more of these drugs. The Action Plan seeks to drop this number to closer to 3,000 individuals each month being prescribed both opioids and benzodiazepines by 2018. RIDOH will issues clinical guidelines on prescribing these drugs in tandem and also increase medical education about benzodiazepine drugs to prescribers. RIDOH is also helping to lead the charge on a national effort to ensure that the Food and Drug Administration (FDA) puts “black box” warnings on both benzodiazepine and opioid drugs regarding the dangers of using these drugs simultaneously.
Opioid overdose is reversible if the proper antidote is administered in time. Opioid drugs bind to opioid receptors in the brain and slow down functions of the central nervous system. During an overdose, individuals often “forget” to breath as respiration, blood pressure, body temperature, and heart rate all drop. Naloxone is an opioid antagonist drug, often marketed under the brand name Narcan, that blocks opioid receptors and can overturn the effects of said drugs. Naloxone is currently a prescription drug in most states; however, CVS Pharmacy sells Narcan over the counter in Rhode Island as of August 2014, the Providence Journal reports.
Rhode Island’s Action Plan calls for more access to naloxone products, as well as education and training in using the drug for pharmacists, prescribers, and first responders. The Action Plan also intends to increase co-prescriptions of naloxone with opioid drugs and ensure that every community in Rhode Island has easy access to naloxone. Naloxone could have prevented six out of 10 overdose fatalities in Rhode Island between 2014 and 2015, the Action Plan reports.
Rhode Island also reinstated the “Good Samaritan” law in January 2016, which protects individuals from criminal charges or prosecution involving the possession of controlled substances or drug paraphernalia when seeking medical attention, the Providence Journal reports. The new bill also protects individuals at the scene, granting them immunity even if they are in danger of parole or probation violation. This law is an effort to encourage witnesses to an overdose to call 911 without fear of criminal charges or legal recourse. An overdose is a medical emergency that can be reversed with proper medical attention and administration of naloxone.
For addiction involving an opioid drug, the standard of care often includes both behavioral therapy methods and medications, the Substance Abuse and Mental Health Services Administration (SAMHSA) publishes. The FDA has approved three medications for treatment of opioid dependence, the White House Office of National Drug Control Policy (ONDCP) publishes, which include methadone, naltrexone, and buprenorphine.
Naltrexone is an opioid antagonist that helps to prevent relapse and encourage compliance to treatment and recovery, as taking opioid drugs while it is in the system can precipitate difficult withdrawal symptoms. Both buprenorphine and methadone are long-acting opioid agonists that can fill the opioid receptors in the brain and replace other short-acting opioids during detox and into recovery in order to manage withdrawal symptoms and drug cravings.
Prior to Rhode Island’s Overdose Prevention and Intervention Task Force, fewer than 9,000 people were receiving treatment involving medications for opioid dependence per year. The Action Plan calls for over 3,000 more people to receive it per year by 2018. Over 400 providers will be trained in administering opioid dependence medications and subsequent treatments by 2018 as well, thus expanding access to treatment. The Action Plan also plans to increase access to this kind of treatment to individuals at the Department of Corrections.
Also a part of the Overdose Prevention and Intervention Task Force is the opening of Centers of Excellence (COEs) for the treatment of opioid dependence. These COEs will be licensed healthcare facilities that will offer a high quality and standard of care, including expedited treatment and programs licensed to provide medications for opioid dependence. Treatment for opioid dependence can help to prevent overdose, relapse, and incarceration, and save lives, the Action Plan reports.
As a disease, addiction is treatable and recovery is probable with comprehensive treatment. The Governor’s Overdose Prevention and Intervention Task Force plans to double the number of certified peer recovery specialists in the state up to 168 by March 2017, the Action Plan states. Peer recovery services help individuals to become engaged and remain in treatment while working with others who are also involved in recovery, thus providing empathy, understanding, encouragement, and hope. SAMHSA reports that peer recovery services are a form of social support that extend addiction treatment beyond just the clinical environment, and they aid in preventing relapse and therefore also overdose. The Action Plan expands access to peer recovery leaders, or coaches, in outreach sessions and coach encounters to settings like hospitals, EDs, and prisons. A telephone line is to be staffed with recovery coaches for immediate access to peer support during a crisis.
The Action Plan calls for higher rates of retention, more referrals, increased access to medication-assisted treatment, and improved support in recovery. All individuals should have a comprehensive discharge and recovery plan in place before leaving a treatment program, and the Action Plan calls for this as well. Recovery services and aftercare programs can help to sustain recovery on a long-term basis.
Addiction often carries a negative stigma, and the public education and community outreach part of the Overdose Prevention and Intervention Task Force Action Plan intends to overturn this by implementing an aggressive media campaign and strategy to raise awareness in Rhode Island communities regarding the dangers and realities of this disease. The CDC has granted funding to help RIDOH re-launch the PSA “Addiction is a Disease, Recovery is Possible.”
The Rhode Island Governor’s Overdose Prevention and Intervention Task Force strives to save lives by preventing overdose, enhancing access to opioid dependence and addiction treatment, and improving peer support and recovery services while educating the public and treatment providers on the disease of addiction and the potential for recovery.